Elevate Clinical Instruction Using Video

Intelligent Video Solutions proudly presents a series by an experienced Clinical Educator, Professor and Communicative Disorders Clinic Director: Ms. Angie Sterling-Orth. Angie will be drawing on over 15 years of Clinical Education experience and 5+ years using software developed by the team at IVS to reflect on a variety of topics important to many Health Sciences Education stakeholders.

Reflection

Reflect… something I direct my practicum students to do every single day. Something I must force myself to do in a purposeful and productive way. Easier said than done, that is for certain. Reflect… why? Why do we insist on this activity? Is it just busywork? Where’s the value? I pause to pose all of these questions as I begin this blog dedicated to the uses of video in clinical learning applications. What I do know about reflecting, is that when done in an intentional and structured way, it allows us as clinicians and instructors to wring every ounce of learning from an experience. Simply having participated in an event is like water dripping from a soaked cloth. Reflecting on the event is the twisting and squeezing of every drop of liquid from the cloth. The Clinical Connection will be a place I can stop and reflect on my specific use of the most powerful and career-changing tool I have encountered during my 20+ years of practice as a speech-language pathologist and clinical professor in communication sciences and disorders (CSD). This first reflection is related to one of the first efficiencies and obstacles I encountered when we hit the ground running with the IVS video observation and recording system implemented in 2010… work-world efficiencies and multi-tasking demands!

I need to take you back to the very beginning. I started as a clinical instructor in a CSD program in 2001. Just starting out I had a supervision load of about 25-30 clinician-client pairs each semester. I spent approximately 6 hours per day, four to five days per week, 12 weeks each semester, on a hard bench (without back support), in the dark, in the observation deck. I’d shift from window-to-window, catching 10- to 30-minutes or so of each session, hour-after-hour. I had my clipboard and notepad (not even a laptop at that time!) and I would scribble notes the best I could all day long. I would crawl from the dark depths of the observation deck around suppertime. I would run a copy of my notes and toss the originals into grad student mailboxes. Then I would return to my office to an answering machine full of voicemails and an email inbox loaded with new messages. To this day, I have to pause to wonder what made that daily schedule appealing to me. The answer comes quickly though, I am passionate about my field of speech-language pathology and I thoroughly enjoy guiding undergrad and graduate clinicians to greater heights of clinical practice. However, our outdated clinical observation system was putting up obstacles for all clinical instructors (not to mention, giving me a sore back!). In addition, it was preventing us from using evidence-based techniques in our clinical instruction (such as video modeling).

Finally, in 2010 we gained funding for installation of the new video system throughout our entire speech and language clinic (over 20 therapy rooms!). From that point on, my professional world changed. I was now able to observe several sessions at once, all from my office computer! I could see daylight out my window at all times (which improved my disposition). I was able to see when a clinician was struggling and focus specifically in on that session. I could catch phone calls as they came in, thus bringing a quicker end to games of “telephone tag” with colleagues, students, parents, caregivers, and off-campus supervisors. I was in my office when a struggling student would stop in for a quick assist or to schedule an appointment. I had my computer in front of me the entire time so I could type more written feedback to my clinicians as I watched their sessions and I could respond to emails rather than letting them pile up and bury important notifications. The list could go on. I’m certain the benefits and efficiencies are apparent. However, what caught me by surprise was how I needed to educate myself about working memory risks associated with so much multi-tasking. This was not something I anticipated, even though I work in a field that is quite understanding of the risks associated with challenging our working memory. Once I stepped back and became aware of my shortcomings that were associated with my use of the of our new video recording and observation system, I developed some intentional strategies and “rules” for my own practice. I share these with you in case they are much-needed or to help you prevent some of my mistakes from entering your practice. These include:

Turning my email off (i.e., closing Outlook) when I am trying to watch more than one therapy session at one time.

Checking the caller ID on the phone and only picking up calls from “essential” callers while I’m watching sessions of struggling or beginning clinicians, or when a “can’t miss” task is happening in the session.

Hanging a “stop light” sign on my office door, as needed, while I’m supervising sessions. (As an aside, it was interesting to me that when I was supervising on the observation deck all of those years, students never came back there to disturb me to ask questions. As soon as I started to supervise from my office using our new networked video system, students came in constantly to ask for assistance (colleagues were culprits too). I actually now have a “Yellow Light” sign for my door for whenever I’m watching sessions. It says “Your signal is YELLOW, so proceed with CAUTION! I’m supervising therapy sessions, but if your question is critical, you are welcome to enter. If it can wait, stop back later or shoot me an email. Thanks!”)

Making sure all of my clinicians know that if there is something specific they want me to view from a session, they should let me know. They can usually tell from my notes or from our discussion in our meetings if I have missed something because my attention was focused on a different session, or I was on the phone, etc. I rely on them to tap me on the shoulder if they need or want me to go back to past footage. The new video capture and review system made that a snap!

More than anything else, being very mindful about my online supervision. I make sure my Word document for written notes is up side-by-side with my streaming video windows of my current session(s). I also have an electronic copy of the clinician lesson plan(s) up and on a separate monitor. This way, I know what I’m supposed to be watching for and I can structured my observation and feedback very strategically. (P.S. Having a dual-monitor workstation is SO helpful when using a network based video observation system.)

So none of this is rocket science and every clinical instructor will have his/her own procedures and practices that will be customized around the use of an online application for video capture and observation of practicum students. What will be universal is the need to keep an eye on challenges to working memory so that we get the most from our system to benefit the development of critical clinical skills.

Video Self Modeling

“Video self-modeling” is a buzz word I started hearing only about five years ago. It sounded like a mouthful and I wasn’t even exactly sure what it meant. The context was two colleagues talking about how our new, online video capture system for clinical supervision was allowing him to utilize video self-modeling with his student clinicians on a regular basis and how delighted he was about this opportunity. I nodded along and made a mental note to research this term immediately. Was I doing “video self-modeling”? Was it really an evidence-based practice for clinical instruction and supervision? If so, where was the evidence? If I wasn’t doing it, what was it and should I start doing it? I had a mission to figure out the answers to these questions and make sure I was taking full advantage of our highly sophisticated supervision tool.

By definition, video self-modeling (VSM) is the use of video recording to analyze one’s own behavior. True VSM (Video self modeling) is where individuals observe themselves performing a skill or behavior SUCCESSFULLY on video and having this reflection guided or mediated so that they will be likely to continue more positive and accurate use of the targeted skills. I was relieved to discover that, yes, from the time our video capture system was installed in 2010, I had been using VSM with my student clinicians. I just didn’t know to call it “VSM.” In addition, I had been using it frequently with our clients (but more on that in a future blog). What I decided I needed to do after discovering this term that was new to me, was to make sure I was DELIBERATE and SYSTEMATIC about my use of VSM as a tool for clinical instruction. In doing this, I would be more certain that it would have the positive impact I desired as a tool for my student clinicians to hone their clinical skills and dispositions.

My first step in refining my use of VSM as a tool for clinical instruction was to create a one-page information handout for my student clinicians. Since VSM was a term that was new to me (even though the concept was something that I had already put into action), I figured it needed to be defined for my practicum students and I also wanted to provide them with some research citations on the use of the strategy. I hold a clinical instruction style that insists on being transparent with my supervisees, as I know that being on the same page as them allows for fewer communication breakdowns and greater achievement of clinical outcomes. Then, I put the VSM topic on a weekly agenda for a clinical meeting. I typically have two to four special topic meetings per month with my entire group of assigned clinicians, and VSM was perfect for one of our special topics. At that meeting, I reviewed the concept, showed it in action, and set a plan for all of us to move forward with the technique in a deliberate way. Finally, I developed a form and expectation for my clinicians’ use of VSM as a required component of our clinical experience together. A form to guide student reflections is critical to mediate the strategy in use. It will offer them a framework for reflecting, insist on the tallying of specific skills or behaviors (of their own, like specific use of feedback to the client or deployment of a visual cue, etc.), and keep them from straying towards all of the “oops” moments or mortifying behaviors they might think see in themselves. I assigned all clinicians to complete two detailed VSM reflections per semester (more, as desired and/or needed). For each required reflection, I directed my clinicians to complete the form I provided and then come to our following individual weekly feedback meeting ready to lead the discussion with their VSM reflection as our guide. We’d discuss the reflection and set goals for moving forward.

I’ve now been using VSM as an intentional and structured clinical tool for over four years. Student reporting confirms for me that they are wedded to this strategy for making gains as clinicians. My own observations and evaluations of student clinicians over the past fifteen years assures me that video self-modeling makes a considerable positive difference on a student clinician’s refinement of clinical skills and achievement of overall confidence. My best advice in adopting this as a strategy is to have a format in place, TEACH the technique overtly, keep students focused on POSITIVE clinical skills and behaviors (which creates a situation where the increased use of positive skills replaces any undesirable behaviors), and use VSM reflections as the basis of goal-setting with students. This comprehensive approach with VSM will surely allow you to maximize the use of a video capture system on a daily basis.

Video modeling is the use of video footage showing other people in action to teach a person specific skills. It is widely understood that DEMONSTRATION of a skill or behavior can be a powerful tool for learning. Consider the way in which a person might learn specific dance moves to be able to perform the dance or how one might learn to draw a specific illustration by watching it done (possibly pausing and replaying the demonstration to perfect the motions). Not all behaviors are learned this way, but most humans tend to be highly visual in nature and can learn many skills by seeing things done.

Video modeling holds some terrific potential for teaching behaviors and helping others enhance their skills. It’s quite common for a therapist, teacher, coach, or other facilitator of skills to scour video collections, such as YouTube, for footage of “just the right model” when working with a wide range of learners. It can be frustrating to consistently fall short of finding just the right model to show. On the other hand, it can be extremely time-consuming and loaded with obstacles when trying to film, edit, and present original video model creations. Navigating expensive video cameras, placing tripods, running the equipment, negotiating the capture of a quality audio feed, transferring files from a video recorder to a computer, etc. are steps in this process that overwhelm a well-intentioned clinician or teacher. The creation of video productions quickly becomes a powerful technique that gets abandoned too soon.

A video capture system can provide customization opportunities and efficiencies so that appropriate video footage can be efficiently planned, captured, edited, and presented. Mock role plays, real-life scenarios, and guided and narrated step-by-step displays can be performed, recorded, edited (if needed), and saved for repeated use. It doesn’t take much time before you can have a fully developed set of video models stored and organized for repeated use for clinical, instructional, or coaching purposes.

At the beginning of this process, take care to include a planning stage. Determining and securing the appropriate video capture system, mapping out the skill(s) to be highlighted, selecting the appropriate context and materials, and securing participation of logical role-play participants are all key elements of the planning process. Taking time to be intentional about all of these dimensions will better assure that you collect footage that will need minimal editing and that will be a positive match for the desired acquisition and/or refinement of targeted behaviors/skills. Keep demonstrations succinct and resist from having them run long. It is better to have many, shorter video models (approximately 3-5 minutes in length) than to have long and cumbersome productions that have to be edited or broken into parts in order to use. Breaking learning down into smaller steps can allow more learners to be successful.

When using the created videos with the intention of teaching skills, the following efforts should be consider:

The facilitator should make sure to provide appropriate instruction to compliment the video footage (i.e., MEDIATE what’s happening on video before, during, and/or after the showing of the footage). This additional information and feedback will vary depending on the age of the learner(s), purposes of the lesson, and skills being targeted.

Repeated viewing of the video models should be utilized. Do not assume that a one-time viewing can allow someone to learn a desired skill.

Solicit reflection from the learners related to the video footage. Some possible prompts for encouraging reflection could include: What did they just watch? What was interesting? What was successful about what they saw? What looked difficult? Are they able to do what they saw on video? If not, why not? How does this relate to them?

Structure guided follow-up practice to promote acquisition and generalization of skills. Use the video model as a launch pad into a practical application activity. Set the learner(s) up to now engage in a similar or related type of task/activity. Or, in some cases, the specific behavior that was demonstrated on video will need to be mastered by the learner, so the video can be played back many times as the skill is being rehearsed.

A classic example of the use of video modeling in speech-language therapy services would be having a pair of college students role-play a discussion about a controversial topic from a course they’re taking together. The pair of students could demonstrate a “lively” or somewhat contentious discussion about this topic, while negotiating, listening carefully to each other (showing verbal and nonverbal behaviors that demonstrate active listening), and come to a resolution or compromise to move forward with their collaborative project. This video could then be shown to a group of high schoolers with high-functioning autism who are working to refine their own skills of positive nonverbal behaviors, sharing information in a group, and disagreeing appropriately. Having the neuro-typical college students modeling these skills in the role-play video can be a launch pad to having the high school students see the behaviors in action and then practice something similar with each other, bridging the conversation to their real-world contexts throughout.

The possibilities for using created video models are endless. Being intentional and strategic about the use of video capture to create these robust arsenals of footage can better assure efficiencies, more positive results, and great professional reward!

Video self-modeling is best defined as using mediated video capture and playback to allow a person to see him/herself in action for the purpose of acquisition and refinement of specific targeted skills or behaviors. This is a more specific type of video modeling that uses the client/patient/student as the person performing the action. Video self-modeling can produce powerful results. Within VSM the client/student/learner becomes the model and is captured on video that is then used to playback so that they can witness themselves in action. Three main factors that support the notion of VSM as a powerful teaching tool include:

Modeling in general is a way in which humans learn many skills. Seeing a skill or behavior in action is just one way we can learn. As mentioned in a previous post, humans are highly visual in nature, thus watching something done (like a dance, sign language, a puzzle, etc.) can be one way in which we learn. Whether the person demonstrating the target is an unfamiliar “model” or the person him/herself, modeling can be very powerful.

Human self-efficacy (Bandura, 1994) can support refinement of skills. Self-efficacy is simply seeing ourselves as being successful, competent, or able to complete the targeted skill or perform a behavior. When a person sees him/herself in action, demonstrating something with accuracy, he/she is fueled in a positive way that tends to encourage more and continued success in that area.

We can make some adjustments and have some level of correction as we learn from our mistakes. It’s cliché to say, but some of the most powerful learning can come through having seen ourselves “mess up” or perform in error. We must use great caution with this principle, especially with our fragile learners. More on this element as VSM is discussed in further below.

With all of this being said, it is clear that use of VSM holds great utility in helping a wide range of learners acquire and refine skills. As with production of video models discussed in the previous blog post, we should use VSM with careful planning and implementation. Some tips to consider include:

Most use of VSM should be done with playback of and attention to the POSITIVE or ACCURATE display of client/learner skills or behaviors. The focus should be on “tapping them on the shoulder” so they can see themselves in action being successful. This is to increase self-efficacy and preserve self-image. Negative examples should be skipped past or edited out of footage.

Differentiate between “incidental” video capture of structured or authentic contexts versus “intentional” use of VSM. If the camera is running in the background and all activity is captured, those “ah-ha” moments or terrific positive examples are likely not to be missed. While you may end up discarding much of what is captured, you can go back to just the important pieces to review with the learner to strengthen targeted skills or reinforce behaviors.

Plan for the more intentional and structured practice, especially at the beginning stages of the learning of a skill. Some skills will need to be broken down into smaller steps so that the learner can be successful from the start. Plan for those discrete lessons at the start and capture strategically, playing back the footage for the learner to review to see their own accomplishments along the way.

In small doses, and with appropriate learners, consider the use of the negative model. When working with a person on the very fine-tuning of a skill, after so much success has been shown and reinforced, infusing a bit of attention to what’s left to be learned could be warranted. Be sure to show positive examples at least three times as often as the negative and keep constructive feedback associated with errors so that they are shown for the sake of learning rather than “shaming” or embarrassing the learner. Remember the need to keep self-efficacy high.

The use of VSM holds great potential and reward. The following list of citations are offered to show just a small subsection of speech and language specific application of VSM:

Using Video Capture for Role Play

A wide range of related medical and educational fields rely heavily on the acquisition of a specific set of knowledge, skills, and dispositions in order for the pre-practice professional to become effective in his or her future role. To develop undergraduate and graduate students for roles as counselors, law enforcement agents, healthcare providers, teachers, coaches, and endless others, it takes a strategic scope and sequence of a curriculum delivered through a combination of classroom instruction, supervised rehearsal, and real-world practice. Many skills being facilitated are best learned through demonstration of and rehearsal with the specific behaviors, rather than hearing or reading about the “how-to” associated with the use of the skill. For example, learning how to interview another person can be spelled out in printed form, but it cannot be fully understood and mastered without simulated and real practice interviewing others. At the start of that learning process, it is not feasible or appropriate to have beginning students engaged with actual patients, clients, customers, etc. Role-play simulations are a widely-respected, evidence-based technique for learners to transition from classroom or textbook instruction into real-world application of targeted behaviors (Lorenzo, 2014; Lewsi, et al., 2013; Oh & Solomon, 2014; Lane, Hood, & Rollnick, 2008; Alkin & Christie, 2002; Nikendei, et al., 2005).

Role-play is just one technique in teaching and fits into a bigger category of simulation techniques (Alkin & Christie, 2002). Simulations can grow to be complex, layered, and lengthy. On the other hand, role-play (either on its own or within a more complete simulation activity or process) can be succinct, quick, and precise (Alkin & Christie, 2002). Role-play activity to target specific skills and behaviors makes learning interactive, responsive, and individualized. The most complete and effective use of role-play is facilitated by intentional use of the practice and includes a feedback component that is easily accomplished through the use of video capture and review of the rehearsal. Educators using role-play activity to heighten learning are encouraged to think more completely about this process so that the maximum advantage is obtained. The following comments and suggestions are offered to either get someone started with this process or to take professional use of role-play to the next level.

Consider infusion of role-play tasks into traditionally-taught classroom topics. For example, if previous attention to something like the use of verbal contingencies to respond to patient/client/student behavior has been typically handled through a classroom lecture or textbook reading, redesign that lesson by adding role-play scenarios for the learners to use to actually apply contingencies while engaging with another person. Many skills cannot be efficiently or fully realized without actual application of the concept. Dig into course outcomes within the curriculum, or professional standards, to identify those topics and add role-play to the current teaching methodology and course requirements.

Make a plan for the specifics associated with all role-play practice. Consider details such as:

Will it be spontaneous or scripted (with the learners outlining a script or an instructor-provided format)?

Will a prompt be provided or will it be open-ended?

How many individuals need to be involved?

Will the learner be paired with other learners or will “hired” practice partners be brought in?

How much, if any, “sabotage” will be inserted or applied by the role-play partner or instructor?

Are props/materials needed?

Will role-play practice be foreshadowed for students, or more impromptu in nature?

Will a time limit be set/needed? Will timing be displayed during the role-play?

Do you plan on offering a demonstration of the practice scenario to set a model, or will students be expected to complete rehearsal based on lecture- or textbook-based learning?

Prior to and/or during the role-play, provide students with a guide, particularly focused on the desired outcome(s) of the practice. State what needs to be accomplished and provide any other specific instruction. Unless it is the desired intent of the role-play, do not leave students confused or guessing at the purpose of the practice or time will be lost and negative practice will occur.

Pair role-play activities with video capture and review. While role-play can be used as a teaching-learning technique without video capture, it can fall dramatically short without this value-added component, especially if the educator is not available to give real-time feedback to the learner(s). Even in the case of online instructor observation of the role-play, without video capture and review, learners cannot benefit from seeing themselves in action, completing self-evaluation, and seeing positive examples of their peers in action. Furthermore, use of video capture allows the educator to compile a collection of footage of skills in action that can be used and reused during future classroom and clinical instruction.

When conducting video review of performed role-plays, use an intentionally-structured feedback format. This can include oral notes, written narrative, rating scales, and checklists. Make sure to provide feedback calling attention to the positive or “correct” use of behaviors/skills. In addition, make sure constructive feedback includes instructor think-aloud statements (such as “When I see you sitting back in the chair like that with your arms folded, it makes me believe that you’re disinterested in what your patient has to say”) along with specific suggestions for change (such as “Next time, lean forward a bit more and fold your hands on your notepad or place your arms on the chair so that you send a more inviting signal”).

Share the video capture of role-plays with the students and encourage their reflection and self-evaluation. As with instructor feedback, carefully design the manner in which you guide and receive these reflections and self-evaluations from students. Respond to their feedback so that you can confirm or offer suggestions associated with what they observed while watching the role-play.

Role-play work that is accompanied by video capture and review can strengthen the acquisition of critical knowledge, skills, and dispositions of learners across a wide range of training programs. This teaching practice can bring big rewards to many.

Alkin, M., and Christie, C. (2002). The use of role-play in teaching evaluation. American Journal of Evaluation, 23(2), 209-218.

Lane, C., Hood, K., and Rollnick, S. (2008). Teaching motivational interviewing: Using role play is as effective as using simulated patients. Medical Education.

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